Provider Demographics
NPI:1053921619
Name:MONDESTIN, AMONISE
Entity type:Individual
Prefix:
First Name:AMONISE
Middle Name:
Last Name:MONDESTIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 CYPRESS KNEE DR
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2116
Mailing Address - Country:US
Mailing Address - Phone:561-853-5260
Mailing Address - Fax:
Practice Address - Street 1:4600 CYPRESS KNEE DR
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2116
Practice Address - Country:US
Practice Address - Phone:561-853-5260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-07
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6907014311Z00000X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL106070200Medicaid
FL6907014OtherADULT FAMILY CARE HOME
FL255059OtherCERTIFY NURSING ASSISTANT